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FIRST TRIMESTER BLEEDING

FIRST TRIMESTER BLEEDING. SPONTANEOUS ABORTION ?30%, usu self-limited ECTOPIC PREGNANCY ?1%, most dangerous MOLAR PREGNANCY 0.1%, cookbook. SPONTANEOUS ABORTION. SPONTANEOUS LOSS, PRE-VIABLE <20 WKS, <500 GM 30% PREVALENCE 80% 1 ST TRIMESTER-”EARLY”. RISK FACTORS. AGE

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FIRST TRIMESTER BLEEDING

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  1. FIRST TRIMESTER BLEEDING • SPONTANEOUS ABORTION • ?30%, usu self-limited • ECTOPIC PREGNANCY • ?1%, most dangerous • MOLAR PREGNANCY • 0.1%, cookbook

  2. SPONTANEOUS ABORTION • SPONTANEOUS LOSS, PRE-VIABLE • <20 WKS, <500 GM • 30% PREVALENCE • 80% 1ST TRIMESTER-”EARLY”

  3. RISK FACTORS • AGE • 10%@20, 20%@35, 40%@40, 80%@45 • SAB HX • 5% NSVD/NO SAB, 30-40% IF 3 SABS

  4. CAUSES • CHROMOSOMAL ABN’S- 50%-sporadic • CONG ANOMALIES • UTERINE ABN’S-fibroids, synechiae, septae • INFECTIONS • THROMBOPHILIAS-APS, APC res, prothro, etc • DM, THYROID • IATROGENIC-amnio, CVS • SUBSTANCES-caffeine, tob, meth, coc, NSAIDs

  5. APPROACH • ESTABLISH IUP-R/O ECTOPIC-urgent • ESTABLISH VIABILITY-less urgent • CONSIDER INTERVENTION-not all • REMEMBER RHOGAM-all Rh neg • EDUCATE/ SUPPORT/ FOLLOW-UP

  6. ECTOPIC? VIABILITY? • RISK FACTOR ASSESSMENT • absence doesn’t r/o • UTERINE SIZE-decidua to 8 wks • HEART TONES- don’t settle for 2nd best • CERVICAL-open suggestive • TISSUE PASSED-frozen/rush permanent

  7. ECTOPIC? VIABILITY? • HCG • ?serial- not if visualized on sono • ?serial sono better if not definitive • SONOGRAPHY • Gest sac/yolk sac- ?normal appearing • Fetal pole if gest sac MSD >20 • cardiac if fetal pole >6-7wk=CRL >5mm

  8. TERMS • THREATENED-next slide • INEVITABLE-open,SROM,heavy bleeding • INCOMPLETE- • COMPLETE-easiest in retrospect-decresc • MISSED/” BLIGHTED OVUM” • SEPTIC

  9. Threatened SAB • Vaginal bleeding +/- cramping • 30-40% pregnancies bleed; 1/2 SAB • more symptoms, small for dates, subchorionic bleed-poorer prognosis • fetal cardiac activity- better prognosis • Rx- observation

  10. INTERVENTION • DO I NEED TO INSTRUMENT? • Where/ what instrument? • How soon?-septic vs bleeding vs missed • Lam’s? EGA by sono, blighted ovum • DO I NEED FROZEN SECTION ? • Rush permanents vs routine

  11. OPTIONS • EXPECTANT • <10-12wk, 80-90% res, slower • SURGICAL • ?ectopic, septic, BLEEDING, missed,>10-12 • Fastest • MEDICAL • <10-12, 80-90% res, faster • Miso 600-800 PV x 1-2

  12. PREVENT ISOIMMUNIZATION • REMEMBER RHOGAM 50mcg IM if < 12 WEEKS 300mcg IM IF > 12 WEEKS

  13. EDUCATION & SUPPORT • ADDRESS GUILT • ADDRESS GRIEF • DEFER PREGNANCY > 3 MONTHS

  14. Recurrent SAB • ?3 consecutive for therapeutic nihilists • ?evid base for recommendations • Outcomes similar- ~70% successful preg • no w/u, + or – w/u , +w/u with or without rx • 50% success after 6 consecutive losses • Uterine eval, day 3 FSH, antiphos syn w/u & misc thrombophilia w/u, TSH, ?fast glu, ?ANA, karyotype • Thrombophilia is in –progesterone supps, doxy are both out

  15. MOLAR PREGNANCY • Aberrant fertilization, fetal origin • 0.05-0.1% incid (US), chorioca 1:30,000 • 1:120 SE Asians, 1:1200 Hispanics, prior mole, age <20 >35, lower parity • 80-90% benign course • most metastatic disease curable

  16. CLASSIFICATION • HYDATIDIFORM MOLE =GTD • COMPLETE • PARTIAL • PERSISTENT/INVASIVE MOLE=GTN • CHORIOCARCINOMA=GTN • PLAC SITE TROPHOBLASTIC TUMOR= GTN

  17. No fetal tissue 1 sperm + anuclear ovum- 46XX or 46XY GTN risk 20% Fetal tissue 2 sperm + 1 ovum - 69XXY or 69XYY GTN risk 5% Complete & partial mole

  18. CLINICAL FINDINGS • VAGINAL BLEEDING • NO FHT’S • SIZE > DATES • HIGH HCG- >100,000 (nl preg peak < 200,000) • HYPEREMESIS GRAVIDARUM • EARLY PREECLAMPSIA <20Wwks • THYROTOXICOSIS • OVARIAN CYTS ( THECA LUTEIN)

  19. DIAGNOSIS • SONOGRAPHY • PATHOLOGY

  20. W/U • HCG, Rh, TSH, LFP, BUN/Cr • CXR • SONO

  21. TREATMENT • Uterine evacuation • D&C, pitocin running? • Bleeding, perforation, ?ARDS, etc • Serial HCG’s • q wk till negative then q mo for 6-12mo • Should drop rapidly& be negative < 90 days • normal preg usu takes 2-4wk • effective contraception during follow-up

  22. Persistent/recurrent HCG rise • =HCG rise x2 wk, stable x 3wk,+@3mo • ?new pregnancy… • Worry re GTN/metastatic disease • 25%chorioca, 75% persist/invasive mole • Pelvic sono • Consider repeat D&C- up to 40% neg HCG • Cbc, coags, liver, renal labs • CT abd, pelvis, chest, ?head

  23. High risk features • Higher HCG • Time from and characteristics of antecedent pregnancy • Site, size and number of mets • failure of prior chemo

  24. GTN • Occurs 50% after nl preg, 25% after mole, 25% after ectopic/SAB • Vag bleeding or amenorrhea esp prolonged postpartum,very bloody tumors check HCG • Serial HCG’s after molar pregs

  25. Remember rhogam • 300mcg IM with moles

  26. ECTOPIC PREGNANCY • Implantation outside endometrial cavity • High prevalence related to PID prevalence • 98-99% tubal- usu rupturing 6-10 wks • cornual, cervical, ovarian, abdominal rare

  27. High index of suspicion • Assume all female patients are pregnant until proven otherwise • ?9-50yrs, sexual hx reliability, contraceptive failure • Assume all pregnant patients are ectopic until proven otherwise • danger of preexisting diagnosis of SAB

  28. Risk factors • Tubal damage • Prior ectopic • PID 1:24 pregs • pelvic surg- appi, cystectomy, section, TL • Failed contraception • IUD, progesterone only methods, TL, emergency? • Misc. • extrinsic mass, infert, smoking at conception • Absence of risk factors does not rule out ectopic

  29. Clinical Presentation-an evolution- • Pregnancy • amenorrhea, N, V, frequency, rising HCG • Failing pregnancy • vag bleeding, ?tissue, flat/ falling HCG • Growing/ rupturing ectopic • pain (colic, peritoneal irritation, referred), mass, hemodynamic instability, fluid in belly

  30. HCG • >99% ectopics positive • absolute values correlate poorly w/ EGA • relative rise helpful early in gestation • abnormal rise signifies abnormal gestation • note 20-30% of ectopics have normal rise

  31. Lower normal limits HCG rise

  32. Sonography • Primary-Verify or rule out IUP-?heterotopic • Also ectopic cardiac, complex mass, free fluid • “Discriminatory zone” • Endovaginal vs. transabdominal • Availability • Indication-low thresholds symptoms-All?

  33. Sonographycontinued • Gestational sac (vs pseudo sac) • EGA~5wks, singleton 1000-1800 • Fetal pole • EGA~5.5wks, by mean sac diam of 16-20mm • Cardiac activity • EGA~6wks, by 7 wks “minimum EGA” or fetal pole >5mm

  34. DDX • SAB • Molar preg • IUP complicated by: • ovarian cyst complication • fibroid degeneration, torsion • appendicitis • etc.

  35. DIAGNOSTIC ALGORITHM

  36. DIAGNOSTIC ALGORITHM

  37. DIAGNOSTIC ALGORITHM

  38. DIAGNOSTIC ALGORITHM

  39. Treatment options • Expectant • Methotrexate • Surgery

  40. Expectant • Selection criteria • asymptomatic, small ectopic, low falling HCG • Rationale • ?incidence tubal SAB, no therapeutic M&M • Concerns • risk of rupture awaiting resolution

  41. Methotrexate • Inclusion criteria • <3-4cm, unruptured, no liver, renal, heme dis ?no cardiac activity, ?HCG <5000-15,000 • Education/ consent • Workup • CBC/d, AST, BUN/Cr,Type/Rh • Sono • D&C

  42. Methotrexateinformed consent • Alternatives • nature of treatment & follow-up • failure rate, risk of rupture • Side-effect profile • pain, stomatitis, liver, marrow, renal tox • things to avoid • NSAID’s, ETOH, folic acid, intercourse

  43. Methotrexate • Dose • 50mg/m2 • Follow-up • quant HCG 3&6 days after injection • Success • >15% drop on HCG between day 3&6 • follow weekly till negative

  44. ALT METHOTREXATE • 1mg/kg IM every other day to 4 doses • Quant HCG with leucovorin rescue on alternate days • Stop when 15% drop in HCG • ?higher efficacy, less lost sleep

  45. Surgery • Laparoscopy vs laparotomy • Conservative- maximize fertility • salpingostomy • Extirpative- prevent future ectopics • salpingiectomy

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